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[Kanata] Teeth whitening consent form
Teeth whitening Consent - Personal Information Section
Name
(Required)
First
Last
Phone
(Required)
Date of Birth (For Birthday Promotion)
MM slash DD slash YYYY
Email
(Required)
Address
Street Address
State / Province / Region
ZIP / Postal Code
General Teeth Whitening Information
Teeth Whitening is designed to lighten the extrinsic color of the teeth. Significant lightning can be achieved in the vast majority of cases, but the results cannot be guaranteed.
ALL RESULTS VARY
. Whitening gel will not harm your teeth or gums, however, like any other treatment it has some inherent risks and limitations. These are not serious enough to discourage you from having your teeth whitened but should be considered before treatment begins. Medical history that would discourage whitening treatment Pregnancy or lactating women Epilepsy Allergy to peroxide and/or Aloe Vera/Petroleum jelly Medications causing internal staining People under the age of 16 Gum Disease / Open cavities / Leaking fillings or other dental conditions
Dental History
Have you had professional teeth whitening completed before?
Yes
No
Do you have sensitive teeth?
Yes
No
Has your primary dental care provider been concerned with gingivitis, recession or periodontal disease?
Yes
No
Do you have any orthodontic appliances currently on the front side of your teeth?
Yes
No
Do you have internal teeth staining?
Yes
No
Have you had your teeth cleaned recently?
Yes
No
Have you had any dental surgeries completed lately?
Yes
No
Do you have white spots on your teeth?
Yes
No
Do you have any fillings/crowns or veneers along your smile line? (the teeth you see when you smile)
Yes
No
Things to note
People that have braces removed should wait 6 months for cement residue to wear off before getting teeth whitening treatment and people with a piercing or other metal objects in the oral cavity should remove them before the treatment as they may turn black.
(Required)
I acknowledge
You may have sensitivity during and/or after treatment (typically gone within 24hrs)
(Required)
I acknowledge
Gum irritation may be present (white spots/redness)
(Required)
I acknowledge
If you get gel on lips/hands or anywhere outside of the oral cavity there maybe some stinging & wipe spots will occur.
(Required)
I acknowledge
If on lips for a long period of time will blister
(Required)
I acknowledge
If you have white spots present they will illuminate
(Required)
I acknowledge
First hour following treatment only water
(Required)
I acknowledge
First 24 hrs following treatment please avoid staining foods/drinks
(Required)
I acknowledge
If I feel a sharp pain on a particular tooth during the treatment I should stop the treatment and contact my dentist since this could be a sign of an open cavity.
(Required)
I agree
I am aware that I am not in a dental office and that the staff here present is neither dentists or health professionals.
(Required)
I agree
I have read the information provided and understand the possible risks/ limitations to a whitening procedure.
(Required)
I agree
Beauty Time does not offer any advice on oral health. It’s important to visit your dentist on a regular basis.
(Required)
I agree
I understand that liability is limited to the amount paid for my teeth whitening products and that the management/ staff of Beauty Time assume no liability of any kind.
(Required)
I agree
I understand it is recommended that I visit my dentist if I experience any problems after using the teeth whitening products.
(Required)
I agree
I indicate that i am not ineligible as per the criteria listed above
(Required)
I agree
I have read and understand this entire document including possible risks, complications and benefits that can result from the treatment
(Required)
I agree
I am performing this treatment under my own responsibility
(Required)
I agree
I certify that I HAVE HEALTHY TEETH AND GUMS and understand ALL RESULT VARY.
(Required)
I agree
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
May we (Beauty Time Centre inc) take your photo?
(Required)
YES
NO
Photo and Video Consent section
PHOTO/VIDEO CONSENT
(Required)
I, the undersigned, give my irrevocable permission to Beauty Time Centre Inc., (BTCI), and/or
parties designated by BTCI, to photograph/video me and use such photograph(s)/video(s) in any
form of media, for any and all promotional/marketing purposes including advertising, display,
audiovisual or exhibition.
I acknowledge that these images may be used on various platforms owned, controlled by, or
associated with BTCI, including social media, the internet, print and any other suitable medium.
I further consent to the use of my name in connection with the photograph(s)/video(s) if needed
by BTCI and/or parties designated by BTCI.
I understand and agree that I will not receive any payment or compensation for my time or
expenses or any royalty for the publication of the photograph(s)/video(s) or the use of my name
and I hereby release BTCI and/or any parties designated by BTCI from any such claims.
My consent and release shall be binding on me and my estate.
I certify that I have read and fully understand this consent and release, and that all questions
pertaining to this consent have been answered to my satisfaction.
I agree to the photo and/or video policy.
Name
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Signature
(Required)
Parent Or Guardian (if client is under 18 years of age) Name & signature
Parent Or Guardian Name
First
Last
Signature Date
MM slash DD slash YYYY
Parent or Guardian Signature
Receptionist/Technician Section
Receptionist/technician Name
(Required)
First
Last
Signature Date
(Required)
MM slash DD slash YYYY
Receptionist/technician Signature
(Required)
76722
